Lisa Cranley gratefully acknowledges financial support of a Doctoral fellowship from the Canadian Institutes of Health Research. Ann E. Tourangeau is supported by a Career Scientist Award from the Ontario Ministry of Health and Long-Term Care.
Nurses' Uncertainty in Decision-Making: A Literature Review
Article first published online: 24 NOV 2008
©2008 Sigma Theta Tau International
Worldviews on Evidence-Based Nursing
Volume 6, Issue 1, pages 3–15, March 2009
How to Cite
Cranley, L., Doran, D. M., Tourangeau, A. E., Kushniruk, A. and Nagle, L. (2009), Nurses' Uncertainty in Decision-Making: A Literature Review. Worldviews on Evidence-Based Nursing, 6: 3–15. doi: 10.1111/j.1741-6787.2008.00138.x
- Issue published online: 16 MAR 2009
- Article first published online: 24 NOV 2008
- Accepted 28 July 2008
- information seeking;
- literature review
Aim: This paper is a report of the results of a review of the literature conducted with the goal of determining how nurses' clinical uncertainty has been conceptualized in the nursing literature.
Background: Although existing research has advanced the body of knowledge regarding the concept of uncertainty in decision-making, this has been largely from physicians' viewpoints and from patients' perspectives (patients' uncertainty). Understanding how nurses' experience and act on uncertainty remains relatively unreported.
Method: A search of Medline, CINAHL, and PubMed databases was conducted to retrieve literature published from 1990 to 2007. The question guiding the literature review was: How has nurses' clinical uncertainty been conceptualized in nursing literature?
Findings: Little exploration has been done of nurses' experience of uncertainty in practice. Many investigators have not theorized about the uncertainty in their studies, but have described nurses' uncertainty in the context of clinical decision-making. The findings from these studies indicated that unfamiliarity with the aspects of patient care is a source of uncertainty, and nurses tended to rely on heuristics or on the expertise of colleagues as sources of information for practice decisions. Expressing uncertainties as information needs might help guide information seeking and reduce uncertainty. However, studies indicated that nurses have difficulty recognizing or expressing uncertainties, and as a result, information needs are not recognized and information seeking is not initiated.
Conclusions: A more comprehensive understanding of nurses' uncertainty could lead to the development and implementation of strategies to support nurses in their clinical decision-making and practice. Descriptions are needed about how nurses experience and respond to uncertainty in their practice, and the influence of uncertainty on their information needs and information seeking.
Understanding how nurses experience uncertainty and work to overcome it remains unreported in nursing literature and is an area in the domain of nursing practice that requires rigorous theoretical work (Kim 2000). The variation that occurs in clinical practice and the resulting inconsistency in clinical decision-making have largely been attributed to practitioner uncertainty (French 2006). Kitson (1999) stated that perhaps the most important skill for any health care professional to master is the ability to recognize and handle clinical uncertainty. Thompson and Dowding (2001) have argued that for nursing to truly control the quality of its contribution to health care, the characteristics of uncertainty in practice must be described and an evaluation of strategies must be designed and implemented. Indeed, a significant gap remains in our theoretical understanding of nurses' uncertainty in practice. Despite the growing body of theoretical and empirical literature addressing physicians' clinical uncertainty, surprisingly, the study of uncertainty in nurse decision-making has received less attention. As a result, increasing calls have been made by nurse researchers to better understand nurses' clinical uncertainty (Thompson et al. 2002; French 2006), and to examine the types of decisions nurses make in practice (Thompson et al. 2002).
The concept of uncertainty has been studied from a variety of perspectives and disciplines. Thus, several different conceptualizations and definitions of uncertainty exist. For example, uncertainty has been studied in classical probability theory and applied to theories of decision-making. Decision theorists have defined uncertainty as a situation wherein an individual cannot assign probabilities to the outcome of events (or accurately predict them), and they distinguished uncertainty from risk situations in which outcomes have known probability (Luce & Raiffa 1957). In psychology, uncertainty has been differentiated from ambiguity. Ambiguity referred to the nature and structure of cues, whereas uncertainty referred to an individual's state of mind (e.g., confusion) created by ambiguity or ambiguous stimuli (Budner 1962; Norton 1975; Lazarus & Folkman 1984). In information science, the concept of uncertainty underlies the information-seeking process and has been described as a cognitive state created by a lack of understanding or a gap in meaning (Kuhlthau 1993) and the critical link between information and decision-making (Whittemore & Yovits 1973, cited in Kuhlthau 1993). In the health care literature, the concept of uncertainty is largely situated within the context of practitioners' decision-making. Penrod (2001) noted that uncertainty is a well-described concept within the framework of physicians' decision-making (Eddy 1984; Gerrity et al. 1990, 1992, 1995). Seminal studies of uncertainty in the sociology of medicine have been focused on medical education (Fox 1957; Light 1979.
Using philosophical principles, Penrod (2001) recently refined the concept of uncertainty based on literature from several disciplines, including nursing, and proposed the following conceptual definition of uncertainty: “A dynamic state in which there is a perception of being unable to assign probabilities for outcomes that prompts a discomforting, uneasy sensation that might be affected (reduced or escalated) through cognitive, emotive, or behavioural reactions, or by the passage of time and changes in the perception of circumstances” (p. 241). Penrod noted that this conceptual definition of uncertainty is broad enough to include the professional decision-making process.
The purpose of this paper is to report findings from a review of the nursing literature that was conducted to: (1) determine how nurses' uncertainty has been conceptualized in nursing practice, (2) identify what has been reported and not reported in the literature addressing nurses' uncertainty, and (3) identify areas for theory development and further research.
A search of Medline, CINAHL, and PubMed was conducted to retrieve literature published from 1990 to 2007. The keywords searched included: “uncertainty,”“information behaviour,”“information needs,”“information seeking,”“decision-making,”“nurse,” and “nursing.” Reference citations from articles were manually searched to locate additional studies. The question guiding the review was: How has nurses' clinical uncertainty been conceptualized in the nursing literature? Included in the review were English language studies in which registered nurses (staff nurses and midwives) were sampled and addressed nurses' uncertainty in clinical practice. Studies that involved both student nurses and registered nurses together in the sample were also included in the review. Studies were excluded that addressed patients' uncertainty or other health disciplines' uncertainty. Papers were not excluded on the basis of quality but were assessed for relevance in terms of sample and topic area pertaining to the question guiding the literature review.
It was deemed appropriate to give greater importance to the “signal” of the study (value and relevance to the review question or topic) than to its “noise” (the inverse of methodological quality; Edwards et al. 1998). “Scholars have increasingly argued against the a priori exclusion of studies for reasons of quality” (Sandelowski et al. 2007, p. 100). A total of 23 studies were included in the review. Of these, 10 studies indicated nurses' uncertainty and 13 included descriptions of nurses' information needs and information seeking as a response to uncertainty. Of the 23 studies reviewed, five studies also included student nurses in their samples (Wakeham 1992; Tabak et al. 1996; Carr et al. 2001; Brannon & Carson 2003; Dee & Stanley 2005) and one study included nurse practitioners (McCaughan et al. 2005).
Despite the growing body of literature addressing physicians' clinical uncertainty, little exploration has been done of nurses' uncertainty in clinical practice (Penrod 2001; French 2006). The primary theoretical perspective in the nursing literature is patients' uncertainty in illness theory (Mishel 1984, 1988, 1990). A substantial body of knowledge exists about nurses' cognitive processes in clinical reasoning and clinical decision-making, and there is an emerging literature on the types of decisions nurses make in practice; however, one often has difficulty isolating the concept of uncertainty within this literature. Nurse decision-making literature primarily indicates two approaches to clinical decision-making: the rationalist perspective and the phenomenological perspective (Tanner 1987). The rationalist perspective is based on the notion that decision-making derives from a logical sequence of cognitive processes. Investigators using rationalist perspectives have used decision analysis or information-processing theory as theoretical frameworks. The phenomenological perspective has been used to describe the context of decision-making in the natural environment (clinical practice setting; Bucknall 2000). Theorists who hold a phenomenological perspective contend that action precedes rational analytical thought, which is characteristic of expert performance (Benner 1984).
Many scholars have described nurses' uncertainty in the context of clinical decision-making (Baumann et al. 1991; Tabak et al. 1996; Cioffi & Markham 1997; Cioffi 1998, 2000; Benner et al. 1999; O'Connell 2000; Carr et al. 2001; Brannon & Carson 2003; Hedberg & Larsson 2003; see Table 1 for study characteristics).
|AUTHORS AND YEAR OF PUBLICATION||PURPOSE||SAMPLE AND SETTING||RESEARCH DESIGN AND METHOD||KEY FINDINGS|
|Brannon and Carson (2003)||To examine the influence of nursing expertise and information structure on diagnostic certainty in decision-making.||n= 216 nurse experts, student nurses (novices), and non-nurse participants (as comparison group). US.||Quasi-experimental design. Participants read two patient scenarios, one structured (consistent information) and one unstructured (inconsistent information). Adapted from Tabak et al. (1996) study.||1. Expert and novice nurses reported greater certainty with structured information. 2. Expert and novices' preexisting cognitive schemata for processing unstructured information did not increase their certainty levels.|
|Hedberg and Larsson (2003)||To describe how nurses make intervention decisions in clinical practice.||Convenience sample of six registered nurses with at least 5 years of nursing experience, working on a hospital medical ward, geriatric rehabilitation ward, and a primary health care unit in Sweden.||Qualitative, descriptive study. Observations and audio-tape recorded interviews.||1. Collegial verification of information gathered was a form of corroboration to reduce nurses' uncertainty. 2. Nurses described “being one step ahead” for an anticipated situation to reduce uncertainty and enable them to act independently during decision-making.|
|Carr et al. (2001)||To explore nurses' constructed meaning of nursing in the community.||Convenience sample of community nurses and students (sample size not specified). Two National Health Service (NHS) community trusts in the United Kingdom.||Hermeneutic phenomenology. Six focus group interviews; five episodes of observation with concurrent interviews; 18 recorded practice narratives.||1. Sources of uncertainty were: unpredictable practice context; nurse–patient power balance; exposure to diverse patient needs; dealing with uncertainty when alone. 2. Uncertainty was not a highly visible concept to students.|
|Cioffi (2000)||To explore nurses' experiences of making decisions to call emergency assistance to their patients.||n= 32 staff nurses from wards/units (other than intensive care) from two hospitals. Australia.||Qualitative, exploratory, descriptive study. Unstructured interviews.||1. Sources of uncertainty in the decision-making situation were: unfamiliarity with the patient and doubts about whether the patient met the medical emergency team (MET) criteria. 2. MET calling commonly occurred in conditions of high uncertainty.|
|O'Connell (2000)||To describe the processes used by nurses to determine, deliver, and communicate patient care.||n= 27 nurses working in many acute care settings. n > 50 informal nurse interviews and observation. Australia.||Exploratory, descriptive study. Grounded theory approach. Interviews, observations, and patient chart audits.||1. To work through obscurity and uncertainty in patient care, nurses used a process of enabling care, by making sense of the situation and minimizing uncertainty (e.g., adapting work practices, such as listing assessment data in the care plan and prioritizing care).|
|Benner et al. (1999)||To articulate the nature of critical care nursing practice.||n= 205 staff and advanced practice nurses. Hospitals and agency sites. US.||Descriptive, interpretive, two-phase study. Interviews and participant observations.||1. Provides insight into the concepts of clinical grasp and inquiry and clinical forethought in nine domains of practice.|
|Cioffi (1998)||To examine nurses' decision- making processes in triage assessment situations.||n= 20 emergency room nurses from teaching and district hospitals with varying levels of nursing experience. Australia.||Descriptive approach. Participants were given six simulated triage cases. Verbal protocols were collected. Think aloud technique.||1. All nurses used more heuristics in conditions of higher uncertainty, with the representativeness heuristic being relied on the most. 2. More experienced nurses used more past triage experiences in their decision-making processes and held higher levels of correctness than did less experienced nurses.|
|Cioffi and Markham (1997)||To examine the relationship between the use of heuristics and complexity in decision tasks.||n= 30 midwives. Australia.||Descriptive approach. Simulated patient assessment situations with verbal protocols and think aloud technique.||1. Heuristics were used more frequently when uncertain (highly complex case) than in low complexity cases. Example of high uncertainty case simulation = antepartum hemorrhage.|
|Tabak et al. (1996)||To examine the effect of experience and information consistency on nurses' decision-making.||n= 92 experienced hospital nurses (at least 3 years experience) and n = 65 senior year nursing students. Israel.||Quasi-experimental design. Participants were given two scenarios, one with consistent diagnostic information and one with inconsistent information. Certainty ratings (0–100%) and decisional difficulty (four items rated on a 6-point scale).||1. Experts were less certain when their decision was based on symptoms that were inconsistent with the diagnosis than were students. 2. The effect of nurses' expertise on certainty and ease in decision-making were moderated by information consistency.|
|Baumann et al. (1991)||To examine nurses' confidence in their decisions of treatment choice in the context of rapid decision-making.||n= 40 intensive care unit nurses from two hospitals. Canada.||Mixed-methods design. Six case vignettes were administered in interviews. Among other questions, nurses were asked how certain they felt their initial plan was the right thing to do (scale from 1 = not at all certain to 4 = very certain).||1. Nurses disagreed as to what the appropriate interventions would be and the experts differed in their quality ratings of interventions. 2. All felt moderately or very certain that their initial choice would be the right thing to do.|
The findings from this body of literature were characterized under two main themes: (1) sources of uncertainty and coping strategies, and (2) degree of uncertainty in a decision task. These themes were derived from patterns noted in the findings in the studies concerning uncertainty. In this narrative review, studies with comparable findings were summarized and interpreted to draw conclusions about the current state of knowledge of nurses' uncertainty in the context of decision-making. The first theme included studies by researchers using qualitative methods. The second theme mostly included studies by researchers using quantitative methods and included studies that indicated uncertainty in similar ways.
Sources of Uncertainty and Coping Strategies
Benner and colleagues (1999) researched clinical judgment, skill acquisition, and clinical grasp of a situation, shedding light on the phenomenon of clinical uncertainty. They suggested that nurses attempt to reduce uncertainty by gaining a grasp of the clinical situation. Benner et al. (1999) contended that clinical grasp of a patient's situation is a perceptual skill that enables clinicians to recognize when they do not have a good understanding of a clinical situation. For the expert, clinical inquiry (search for understanding) is initiated by not understanding the clinical situation. Expert nurses, through their experience, have greater cognitive repertoires to rely on for clinical judgment and problem solving than do novice nurses. Their cognitive repertoires include pattern recognition and skilled know-how. As clinicians experientially learn in practice, fewer clinical situations are puzzling because some transitions in a patient's condition are predictable (Benner et al. 1999). Benner and colleagues' research indicated that clinical experience is an important source of evidence for nurses' decision-making. This seminal work provides a basis for further questioning to explore the phenomenon of nurses' uncertainty. For instance, do nurses search for understanding in response to uncertainty? What motivates nurses to seek further information?
Investigators exploring hospital nurses' decision-making processes indicated that uncertainty stemmed primarily from intervention decisions (Cioffi 2000; Hedberg & Larsson 2003). Cioffi (2000) explored hospital nurses' experiences of making decisions to call emergency assistance for their patients (excluding intensive care). She found that nurses experienced uncertainty when considering calling the medical emergency team (MET). The sources of nurses' uncertainty were unfamiliarity with the patient and doubts about whether the patient met the MET criteria. Hedberg and Larsson (2003) explored how nurses make decisions on intervention measures in clinical practice to better understand how they use their knowledge and experience during the decision-making process.
The authors explored questions related to decision-making during patient assessment, intentions, nursing knowledge, previous experience, and interventions. The decision-making process on intervention measures comprised three interacting activities: observation of cues related to the patient situation, confirmation of information gathered (through collegial verification), and implementation of action strategies. Uncertainty stemmed from the nurses being unsure of their interpretation and choice of interventions.
To cope with uncertainty, the nurses relied on experience (pattern recognition; Benner et al. 1999; Hedberg & Larsson 2003), worked preventively for anticipated events by being “one step ahead” (Hedberg & Larsson 2003), or conferred with their peers (Cioffi 2000; Hedberg & Larsson 2003). However, from a community nursing perspective, Carr et al. (2001) found that in the absence of opportunity to collaborate with colleagues, nurses shared decision-making with their patients. Carr et al. explored community nurses' and students' constructed meaning of nursing, highlighting sources of uncertainty distinct to community nursing. The sources of uncertainty comprised issues of power balance in nurse–patient relations (power shift towards the patient), exposure to diverse patient needs (e.g., encountering facets of patients' lives), and inability to confer with colleagues when making decisions.
O'Connell (2000) explored the process used by hospital nurses to determine, deliver, and communicate patient care. She found that to overcome the problem of being in a “state of unknowing” the nurses used the process of enabling care: working through obscurity and uncertainty. The state of unknowing was linked to many factors, such as the existence of a fragmented and inconsistent method of determining and communicating patient care, and work conditions of uncertainty. In response to being in a state of unknowing, the nurses made sense of the situation (e.g., drawing on the known) and decreased their uncertainty by adapting work practices, taking control, and backing up (e.g., minimizing medication errors). For instance, the nurses adapted work practices by listing assessment data in the nursing care plan and juggling their workload by prioritizing care.
In summary, these studies' findings indicated the sources of uncertainty and how nurses coped with their uncertainty. Studies further indicated how uncertainty varied as a function of practice settings.
Degree of Uncertainty in a Decision Task
Five studies were representative of the second theme, the degree of uncertainty in a decision task (Baumann et al. 1991; Tabak et al. 1996; Cioffi & Markham 1997; Cioffi 1998; Brannon & Carson 2003). Investigators for these studies measured the degree of uncertainty in a specific decision task. Similar study purposes and findings were grouped together for synthesis, and decision tasks were organized according to phases of the nursing process. These included tasks involving patient assessment situations (Cioffi & Markham 1997; Cioffi 1998), decisions about diagnosis (Tabak et al. 1996; Brannon & Carson 2003), and nursing intervention decisions (Baumann et al. 1991). The study measures used by investigators showed how nurses' uncertainty was conceptualized and operationalized in a decision task. Uncertainty was operationalized as level of confidence in decision-making (Baumann et al. 1991; Tabak et al. 1996; Brannon & Carson 2003), decision variation across individuals (Baumann et al. 1991), and decisional difficulty (Tabak et al. 1996; Brannon & Carson 2003) or level of complexity in decision-making (Cioffi & Markham 1997; Cioffi 1998).
Cioffi and Markham (1997) examined the relationship between the use of heuristic strategies (shortcuts in reasoning or rules of thumb) by midwives and task complexity in (simulated) clinical decision tasks in the assessment phase of patient care. The authors investigated three heuristic strategies used by midwives with varying levels of experience in complex decision tasks, based on classic heuristic principles identified by Tversky and Kahneman (1974): representativeness, availability, and anchoring and adjustment.
Representativeness was the use of previously encountered similar cases to make judgments; availability was the ease with which instances of similar conditions came to mind. Anchoring and adjustment were situations in which the decision maker started from a baseline and adjusted from this anchor point to take account of individual patient characteristics and arrive at a final estimate. Level of complexity was operationalized as degree of relevant information and level of predictable relationships. Low complexity represented low uncertainty, which had a higher degree of relevant information and predictable relationships (e.g., the case simulation of uncomplicated established labour). The results showed that when uncertainty was not resolved by the patient information collected over the assessment period, the midwives relied increasingly on the use of heuristic strategies as a way of simplifying the complexities of their judgment tasks. Representativeness was identified more frequently in the high than in the low case, but was the dominant heuristic in both.
In a subsequent study, Cioffi (1998) examined emergency nurses' decision-making in triage assessment situations by testing the effects of experience and uncertainty on triage decision-making. The level of complexity of each case simulation was assessed from the perspective of uncertainty and relevance of information. A decision under uncertainty was regarded as a function of the decision-maker's experience of the complexity of the judgment task. The author found further support that in conditions of higher uncertainty (complex cases), the nurses used more heuristics than in conditions of less uncertainty. The nurses used similar cases from their past experiences in triage decision-making, with experienced nurses reporting more use of past triage experiences.
Tabak and colleagues (1996) examined the effect of experience on decisional difficulty and certainty in diagnostic decision-making. They hypothesized that experienced nurses have greater difficulty in decision-making and are less certain than are novice nurses (nursing students in their senior year). They argued that experienced nurses who have inconsistent information, defined as a set of symptoms inconsistent with the diagnosis, may require more time to explore alternative hypotheses of which novice nurses may not be aware. The nurses were asked to rate their decisional difficulty and level of certainty and confidence in reaching a diagnosis for two scenarios. They found that the effect of the nurses' expertise on their certainty and ease in decision-making was moderated by information consistency. Experienced nurses were less certain when their decision was based on symptoms that were inconsistent with the diagnosis than were novice nurses. Experienced nurses used cognitive schema based on past experiences to evaluate each scenario. Using scenarios adapted from Tabak et al. (1996), Brannon and Carson (2003) also examined the influence of nursing expertise and information structure (consistency) on certainty in diagnostic decision-making. The participants were asked to generate a diagnosis for each scenario and rate their level of confidence (certainty) in their diagnoses.
The authors found that the nurses reported greater certainty with structured information (e.g., one diagnostic possibility) compared with unstructured information. These two studies found that the effect of the nurses' expertise on uncertainty in diagnostic decision-making was moderated by information structure. These findings are consistent with those of Cioffi and Markham (1997) and Cioffi (1998), who reported that information structure (relevance) had a role in nurses' uncertainty in decision-making, and that nurses relied on their past experience when uncertain.
Baumann and colleagues (1991) developed a measure of uncertainty that reflected their conceptualization of the nature of nurses' uncertainty: micro-uncertainty, defined as the degree of confidence expressed by an individual about his or her decision, and macro-uncertainty, defined as the extent to which these decisions varied across individuals (e.g., practice variation).
In their study addressing overconfidence and uncertainty among intensive care nurses, the nurses were provided with vignettes that described critical care situations (in the context of rapid decision-making) and were asked to develop interventions and a plan of care. Among other questions, the nurses were asked to rate their level of certainty that their initial plan was the right thing to do and what percentage of nurses they thought would have done “something different.” They found that almost every nurse selected a different sequence of actions, and there was considerable variation as to the timing of the interventions. The nurses disagreed as to what the appropriate interventions would be (macro-uncertainty), and the experts differed in their ratings about the quality of particular interventions. However, all felt moderately or highly certain that their initial choice would be the right thing to do. Some intensive care nurses did not appear to perceive that macro-uncertainty existed. This finding led to the question: How do nurses express their clinical uncertainty and information needs?
To summarize, what is known about how uncertainty has been conceptualized in the nursing literature is that it includes sources of uncertainty (e.g., not having a good understanding of the clinical situation) and strategies to reduce uncertainty (e.g., drawing on colleagues' experience). In the context of a clinical decision task, uncertainty has been described as the degree of confidence and variation in decision-making and the difficulty or level of complexity in a decision task. Much remains unknown about nurses' uncertainty. For example, how do nurses describe or conceptualize their experience of uncertainty in practice? What structures embody the articulation and sharing of uncertainty (French 2006)? Do nurses search for understanding in response to uncertainty?
Information Needs and Information Seeking
Thirteen studies were reviewed that indicated nurses' information needs and information seeking as a response to uncertainty (see Table 2 for study characteristics).
|AUTHORS AND YEAR OF PUBLICATION||PURPOSE||SAMPLE AND SETTING||RESEARCH DESIGN/METHOD||KEY FINDINGS|
|Doran et al. (2007)||To describe nurses' information needs for point-of-care information collection and utilization with the aim of developing an electronic system.||N= 51 total sample: n= 35 staff nurses working on medical and surgical units in two acute care hospitals, and n= 16 nurses from two home care nursing provider agencies. Canada.||Cross-sectional, mixed method design. Work sampling and focus groups.||1. Hospital staff nurses often sought information away from the point of care. 2. The most frequent source of information was nurse colleagues. 3. Nurses' top priorities for information were vital signs data, information on intravenous drug compatibility, drug references, and policy and procedure manuals.|
|French (2006)||To explore the information needs of nurses and their attributions for uncertainty.||n= 48 nurse specialists (3 groups) from 35 health care provider units (National Health Service Trusts). UK.||Constructionist, ethnomethodological approach. Participant observations of a series of meetings to construct recommendations for practice.||1. Factors contributing to uncertainty were lack of available evidence, differences in interpretation of the same evidence, or disagreement with the evidence. 2. Information need was embedded in the subjectively experienced activities of practice.|
|McKnight (2006)||To describe nurses' information behaviours from the perspective of library and information science.||n= 6 critical care nurses in a community hospital. US.||Ethnographic methods. Participant observations and interviews.||1. Nurses' primarily sought patient-specific information, from people, the patient record, and other systems. 2. Many nurses believed that taking time to read published information on duty was both difficult and ethically wrong.|
|Dee and Stanley (2005)||To explore nurses' information-seeking behaviour.||N= 50 nurses total sample: n= 25 nurses working in three medical facilities in three communities, and n= 25 student nurses working in health care facilities. US.||Mixed methods. Questionnaires, interviews, and observations.||1. Nurses preferred colleagues for medical information. Human resources were perceived as the fastest way to obtain reliable and concise information. 2. Use of online databases was low, and many nurses perceived they lacked database-searching skills.|
|Estabrooks et al. (2005a)||To describe sources of knowledge and their frequency of use among nurses across units and patterns over time.||n= 230 staff nurses in five adult and two pediatric surgical units from four hospitals. Canada.||Longitudinal cross-study approach. Cross-unit and cross-study comparisons. Survey.||1. Nurses preferred to use knowledge gained through personal experience and interactions with co-workers and individual patients than through journal articles or textbooks.|
|MacIntosh-Murray and Choo (2005)||To explore the flow of information in a patient care unit (explored information behaviour in the context of improving patient safety).||n= 26 clinicians (nurses, allied health professionals, and physicians). Canadian teaching hospital.||Ethnographic case study. In-depth interviews, observations, and document review.||1. Information needs may be latent and staff may not recognize their information needs and knowledge gaps and thus information-seeking was not always triggered. 2. Information/change agent key roles: boundary spanner, information seeker, knowledge translator, and change champion.|
|McCaughan et al. (2005)||To describe decisions made by nurses and information sources used for decision-making.||N= 33 nurses total sample: n= 29 nurses and n= 4 nurse practitioners working in general practice. UK.||Exploratory, descriptive. Interviews, observations, and documentary analysis.||1. Daily decisions concerned assessment, diagnosis, intervention, referral, communication, service delivery and organization, and information seeking. Intervention decisions were most common. 2. Personal experience and information from colleagues were considered most accessible and useful for decision-making.|
|Thompson et al. (2001a)||To determine the accessibility of research-based information sources used by nurses.||n= 108 nurses. Medical, surgical, coronary care units in three acute care hospitals. UK.||Mixed methods. Case study design. Interviews, observations, Q sort and documentary audit.||1. Human sources of information were most accessible (e.g., colleagues, clinical nurse specialists, and link nurses). Information seeking followed common patterns regardless of the nature of decisions.|
|Thompson et al. (2001b)||To examine sources of research information nurses find useful for reducing uncertainty in decision-making.||n= 108 nurses Medical, surgical, coronary care units in three acute care hospitals. UK.||Cross-case analysis. Interviews, observations, Q sort and documentary audit.||1. Human sources of information were perceived as most useful in reducing nurses' uncertainty in clinical decision-making. 2. It was not the research knowledge that carried little weight in nurses' decisions but the medium through which it was delivered.|
|Spath and Buttlar (1996)||To explore nurses' information and research needs.||n= 102 acute care nurses from two hospitals working in different positions (80% were staff nurses). US.||Exploratory, descriptive study. Questionnaire.||1. Nurses obtained information from colleagues more than from any other source. 2. Many (60%) nurses indicated the need for diagnosis information was motivation for library use.|
|Blythe and Royle (1993)||To explore nurses' information needs.||n= 32 staff nurses. Medical, haematology, and oncology unit in a teaching hospital. US.||Mixed methods. Observations, interviews, and questionnaire.||1. Nurses sought information from colleagues or quick reference material most frequently because they needed to make quick decisions. 2. Nurses needed direct access to information resources because they could not leave their patients.|
|Wakeham (1992)||To identify the kinds of information sought by nurses and student nurses and explore their information-seeking behaviour.||n= 501 convenient sample. Four health districts. UK.||Survey.||1. Nurses most often needed information related to patient care. 2. Nurses consulted their nursing colleagues when caring for patients.|
|Corcoran-Perry and Graves (1990)||To explore cardiovascular nurses' supplemental information-seeking behaviour.||n= 46 cardiovascular nurses. Three metropolitan hospitals. US.||Exploratory. Mixed methods. Observations with follow-up interview or questionnaire.||1. Nurses sought patient-specific information most frequently and preferred colleagues as sources of information. 2. Relevant information: prior history, assessment data, medication information, and laboratory.|
Studies of nurses' information needs and information-seeking behaviour have primarily been concentrated on the sources of information and resources used. There has been less investigation of nurses' descriptions of their experience of uncertainty and how uncertainty influences recognition of information needs and motivation to seek additional information. French (2006) emphasized the lack of research about how nurses construct information needs from clinical practice and the factors influencing the expression of information need. Thompson and colleagues (2001a, 2001b) examined the sources of research information nurses considered useful when uncertain and found that nurses drew on the expertise of others for practice decisions (e.g., immediate colleagues and clinical nurse specialists). Estabrooks et al. (2005a) found that informal social interactions and personal experience (experiential knowledge) were the two most important sources of practice knowledge for nurses. Investigators have found that nurses tended to ask their colleagues questions primarily because they were accessible and provided concise information (Corcoran-Perry & Graves 1990; Wakeham 1992; Blythe & Royle 1993; Spath & Buttlar 1996; Dee & Stanley 2005; McCaughan et al. 2005; Doran et al. 2007). Further, the nurses preferred to access preprocessed information, such as drug reference information, policies and procedures, and best-practice guidelines (Doran et al. 2007). Blythe and Royle (1993) found that nurses wanted direct access to information resources on the unit because they could not leave their patients. McKnight (2006) reported that nurses believed that taking time to read published information while on duty was not only difficult but also perhaps ethically wrong because it took time away from direct patient care. MacIntosh-Murray and Choo (2005) found that frontline staff nurses' task-driven work and having to cope with heavy workloads limited their attention to and recognition of potential information needs and knowledge gaps, and as a result, information seeking was not always initiated.
Expressing uncertainties as information needs or focused clinical questions might help guide information seeking and reduce uncertainty (Thompson et al. 2001a). However, recent studies have indicated that it is difficult for nurses to recognize, acknowledge, or express their uncertainties (French 2006) and information needs (MacIntosh-Murray & Choo 2005). Information seeking often does not take the form of an articulated question or query (McKnight 2006). French (2006) reported uncertainty about the best course of action among work groups of nurse specialists who constructed evidence-based recommendations for practice. She found that not all areas of uncertainty were articulated as specific information needs, and that there was often more implicit uncertainty than what was expressed.
The key themes in these studies' findings were that nurses conferred with colleagues for information when uncertain, and that information needs did not always translate into an articulated question. Nurses required ready access to information because of lack of time to search for information. Studies of nurses' information needs and information-seeking behaviour have been focused on the sources of information and resources used. However, a significant gap remains in our knowledge about how uncertainty is manifested, and in what ways uncertainty influences recognition of information needs, motivation to seek additional information, and clinical decision-making.
The findings from this review indicated that, although many scholars have not theorized about uncertainty in their studies, they have described uncertainty in the context of nurses' clinical decision-making. Investigators exploring hospital nurses' decision-making processes revealed that uncertainty stemmed primarily from intervention decisions (Cioffi 2000; Hedberg & Larsson 2003) and varied as a function of practice settings. Scholars have described uncertainty as the level of complexity in decision-making (Cioffi & Markham 1997; Cioffi 1998, 2000), degree of confidence in decision-making (Baumann et al. 1991; Tabak et al. 1996; Brannon & Carson 2003), decision variation across individuals (Baumann et al. 1991), and decisional difficulty (Tabak et al. 1996; Brannon & Carson 2003). In decision-making situations involving uncertainty, nurses tended to rely on the clinical expertise of colleagues to reduce uncertainty. O'Connell's (2000) study indicated the concept of “unknowing” in nurses' practice.
The state of unknowing was created by working in a context of uncertainty, which nurses sought to minimize (O'Connell 2000). Multiple ways of knowing exist in nursing, including propositional and nonpropositional knowledge (e.g., personal knowledge; Eraut, 2000 cited in Rycroft et al., 2004). Carper (1978) identified these as empirics, aesthetics, ethics, and personal knowing. Nursing scholars subsequently included two additional patterns of knowing: unknowing (Munhall 1993) and sociopolitical knowing (an appreciation of social, cultural, political, and economic contexts; White 1995). Unknowing represents a condition of “openness” and intersubjectivity to what one does not know (Munhall 1993). To practice evidence-based, person-centered care, practitioners should draw on and integrate multiple sources of knowledge informed by a variety of evidence bases (Rycroft-Malone et al. 2004). “Evidence” includes research, professional knowledge or clinical experience, patient experience and preferences, and information from the local context (Rycroft-Malone et al. 2004). How do nurses blend these different types of evidence for decision-making (Rycroft-Malone et al. 2004)? In what ways are “unknowing” and sociopolitical patterns of knowing integrated with other patterns of knowing to reduce uncertainty?
Nurse scholars have developed models to facilitate and promote the continuous improvement of quality patient care through implementation of evidence-based practice (e.g., Stetler 1994; Logan et al. 1999; Rosswurm & Larrabee 1999; Stetler 2001; Dobbins et al. 2002; Rycroft-Malone et al. 2002). These current approaches to evidence-based practice show individual, organizational, and innovation/research-related factors influencing the uptake of evidence into practice. Evidence-based practice involves acknowledging the uncertainty that accompanies clinical decision-making, followed by seeking, appraising, and implementing research-based knowledge to help reduce uncertainty (Thompson et al. 2002). However, clinical uncertainty is a largely unarticulated aspect of nurses' practice and therefore remains undertheorized. For example, what is the role of cognitive mechanisms, specifically nurses' uncertainty, in influencing evidence-based practice? We need to better understand the role of evidence-based practice in reducing the uncertainties nurses face in their decision-making.
The first step in an evidence-based approach to care is the translation of uncertainty to an answerable question (Johnston & Fineout-Overholt 2005). However, the challenge in this approach to care is the ability for clinicians to recognize their uncertainties (Johnston & Fineout-Overholt 2005). Assisting nurses to recognize and articulate information needs may stimulate interest in evidence-based practice (French 2006), and may change information-seeking perceptions and behaviour (Thompson et al. 2001a).
Theoretical understanding of nurses' clinical uncertainty will provide further insight into the nature of the structures and processes of nurses' uncertainty experiences. This will provide a strong foundation upon which further studies about nurses' uncertainty can extend that knowledge, using a variety of research methods. Developing knowledge about nurses' uncertainty will enable us to identify areas where uncertainty is a feature of decision-making and to which research knowledge can make a unique contribution (Thompson et al. 2001b). Nurses play an integral role in patient care quality and patient outcomes. Quality nursing care is dependent on good clinical decision-making (Thompson & Dowding 2002). Nurses act on the basis of their decisions, which in turn have implications for patient outcomes. In this age of accountability, nurses must be skillful in effectively using evidence-based and clinically relevant information to facilitate the best possible nursing care (Snyder-Halpern et al. 2001). Knowledge about nurses' uncertainty will begin to indicate an important gap in our understanding of how nurses experience uncertainty and the role of uncertainty in influencing their decision-making, information seeking, information use, and ultimately, patient outcomes.
To more fully describe the phenomenon of nurses' uncertainty, researchers should expand decision-making studies by focusing explicitly on uncertainty and its various manifestations. Researchers should also explore uncertainty and its influence on nurses' information behaviour (e.g., recognition of information needs, and information seeking). Specifically, investigators should explore the following:
- • How do nurses articulate their clinical uncertainty?
- • How do nurses think through and act or interact in patient situations about which they are uncertain?
- • What motivates nurses to seek additional information when faced with uncertainty?
- • What strategies facilitate the most appropriate selection of knowledge source under conditions of uncertainty and in the context of rapidly changing care demands (Estabrooks et al. 2005b)?
A comprehensive understanding of nurses' uncertainty will advance nursing knowledge that can guide both nursing education and practice. Theory about nurses' clinical uncertainty can guide educators engaged in teaching nursing students about an evidence-based approach to practice. Understanding nurses' uncertainty can also lead to the development and implementation of strategies to support nurses in their clinical decision-making and practice. For example, understanding how nurses experience uncertainty at different stages in the clinical decision-making process could lead to the design of targeted interventions. Such strategies can guide nurses in managing their uncertainty throughout the process of patient assessment, diagnosis, and planning interventions and care. Tailored educational programs can be developed and used to assist nurses to articulate uncertainty into focused clinical questions to address their uncertainty. Providing opportunities for nurses to obtain real-time feedback and see the relationships between their nursing interventions and their patients' outcome achievement is an innovative example of supporting evidence-based decision-making (Doran et al. 2007) and may create new venues for nurses to seek information at the point of care to reduce uncertainty.
To our knowledge, no review has been published on nurses' uncertainty. This initial work provides an insight and understanding about the concept of uncertainty in nurses' practice, and provides the foundation for subsequent reviews and studies in this area. Specifically, this review can advance nursing knowledge in the area of nurses' uncertainty in three important ways: (1) synthesizing the current state of knowledge of nurses' uncertainty in decision-making so that new directions for research can be identified; (2) providing specific research questions to explore, such as what motivates nurses to seek information when uncertain; and (3) highlighting the significance of and need for theorizing about uncertainty as a key step to informing the development and implementation of tailored interventions to address nurses' uncertainty.
This synthesis indicates that we have only a nascent understanding of how nurses make decisions when uncertain. A significant gap remains in theoretical understanding of nurses' perspectives of uncertainty and information-related behaviour. The extant nursing literature is insufficient in explaining nurses' clinical uncertainty because few studies specifically indicate uncertainty from nurses' perspectives. Exploring how nurses' experience and respond to uncertainty in their practice is an important direction toward understanding how uncertainty influences an evidence-based approach to nursing care and is the key to developing and implementing strategies to manage uncertainty.
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